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r <br /> 4.,, MARION COUNTY PUBLIC WORKS <br /> "I °j"��m BUILDING INSPECTION DIVISION <br /> - t . ..-4 5155 Silverton'Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http:lhvww.co.marion.or.usIPW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, LARRY EISELE ,have authorized <br /> (Property Owner/Print Name) <br /> OWEN.CONSTRUCTION to act as my agent in performing the <br /> (Authorized.Representative l'Print Name) <br /> activities necessary to obtain site evaluations,permits,and other onsite wastewater treatment program <br /> services provided by the Department of Ei virontnental Quality or County Agent on the property <br /> described below in accordance with OAR chapter 340,'division 071. <br /> PROPERTY IDENTIFICATION: <br /> 310 Boulder St N Detroit OR 97342 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description HAMMOND ADDITION BLOCK 3 LOT Tax Lot#(s) 105E01BC07900 <br /> PROPERTY OWNER: <br /> Printed Name: LARRY G EISELE <br /> Signature: _�4,X �y (-. i Date: B/2212022 <br /> ;J :1 hone: 503-730-5193 <br /> Address: 2313 PERKINS ST NE' . <br /> City,State,Zip KEIZER OR 97303 Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: -)« Cot,/ er <br /> Company Name: ot/c)C:tA- (1,45 u<f-r("CI t 6 <br /> Signature: <br /> Date: ' /e e - <br /> Address: Ptt0 l7X 7( 57) Phone: .SO 3 9 q /8. '� <br /> City,State,Zip <br /> ,t1 C.(ir Or 973L'7 Fax: <br /> E-mail Address <br /> r Owev0 lCVlS4-rockt`sI,l hC. co►.-t <br /> f <br /> DEQ License# 3 b`:L� <br /> s-3(-/ COI# ro S 5 6 I <br /> C:V OI 1S\Sl PTIC S•07 Milt to Apply.tloc <br /> MCS-07 Rev 03110 4 <br /> SEPTIC <br /> i <br />